Summary Report for FSPSAs Initiated During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1791 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 3 3 0.888889 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 3 7.142857 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 6 8.031746 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 4 4.000000 $194.0000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 51 51 32.686506 $704.3900 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 0.838889 $37.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.018189 $117.0900 $115.0000
EXIT -EXIT EXIT ASSESSMENT 7 7 8.205555 $410.2800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 15 40.661904 $3049.6400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 33 62 35.033333 $2627.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 20 37 12.150000 $911.2500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 48 85 45.177779 $2507.3700 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 10.285714 $570.8600 $55.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.427778 $6.4200 $15.0000
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Subtotal (Total Children Is Unduplicated) 106 275 190.485647 $11136.5500 $58.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 7 2.083333 $10416.5000 $4999.9200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.427778 $21.3900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 1.144444 $57.2200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 21 21 7.166666 $1648.3200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 40 28.594444 $1429.7200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 155 208 193.592864 $9679.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 2.761111 $69.0300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 0.905556 $45.2800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.027778 $1.3900 $50.0400
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 2.433333 $121.6700 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 29.360320 $2152.7100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 14 53.328572 $1333.2100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 440 497 2256.701581 $112835.1400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 462 688 2388.429364 $23884.3100 $10.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.390411 $89.0100 $227.9900
SENS -V5060 BEHIND EAR HEARING AID
2 2 0.627778 $143.1400 $228.0100
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.200000 $91.2000 $456.0000
SENS -V5264 EARMOLD 4 4 3.122223 $56.2000 $18.0000
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Subtotal (Total Children Is Unduplicated) 478 1510 4971.297556 $164075.1000 $33.0000
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Total 1791 5169.814949 $175211.6500 $33.8900
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Number of Children (Unduplicated) With at Least One Authorization 484